Journal of Obesity & Metabolic Syndrome 2021;30:81-92

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2020 Korean Society for the Study of Obesity

Guidelines for the Management of Obesity in Korea
Bo-Yeon Kim1, Seon Mee Kang2, Jee-Hyun Kang3, Seo Young Kang4, Kyoung Kon Kim5, Kyoung-Bae Kim6, Bomtaeck Kim7,
Seung Jun Kim8, Yang-Hyun Kim9, Jung-Hwan Kim10, Jae Hyun Kim11, Eun Mi Kim12, Ga Eun Nam9, Ji Yeon Park13,
Jang Won Son14, Yun-A Shin15, Hye-Jung Shin16, Tae Jung Oh17, Hyug Lee18, Eon-Ju Jeon19, Sochung Chung20, Yong Hee Hong21,
Chong Hwa Kim22,*; Committee of Clinical Practice Guidelines, Korean Society for the Study of Obesity (KSSO)
1
Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of
Medicine, Bucheon; 2Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan; 3Department of Family Medicine, Konyang
University Hospital, Konyang University College of Medicine, Daejeon; 4International Healthcare Center, Asan Medical Center, Seoul; 5Department of Family Medicine,
Gil Medical Center, Gachon University College of Medicine, Incheon; 6Department of Physical Education, Korea Military Academy, Seoul; 7Department of Family
Practice and Community Health, Ajou University School of Medicine (AUSOM); 8Department of Psychiatry, Konyang University College of Medicine, Daejeon;
9
Department of Family Medicine, Korea University College of Medicine, Seoul; 10Department of Family Medicine, Eulji Hospital, Eulji University School of Medicine,
Seoul; 11Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; 12Department of Dietetics,
Kangbuk Samsung Hospital, Seoul; 13Department of Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University,
Daegu; 14Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St Mary’s Hospital, College of Medicine, The Catholic University of
Korea, Bucheon; 15Department of Prescription and Rehabilitation of Exercise, College of Sport Science, Dankook University, Cheonan; 16Department of Pediatrics,
National Medical Center, Seoul; 17Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine,
Seongnam; 18Central St’ Mary’s Clinic Internal Medicine, Seoul; 19Division of Endocrinology and Metabolism, Department of Internal Medicine, Catholic University of
Daegu School of Medicine, Daegu; 20Department of Pediatrics, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul; 21Department of
Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon; 22Division of Endocrinology and Metabolism,
Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea

Obesity is a prevalent and complex disease. The prevalence of obesity in Korea increased from 29.7% in 2010 to
Received February 28, 2021
35.7% in 2018, with the prevalence of abdominal obesity being 23.8% in 2018. Obesity contributes to medical Reviewed April 13, 2021
costs and socioeconomic burden due to associated comorbidities. The treatment and management of obesity is Accepted April 15, 2021
changing based on new clinical evidence. The 2020 Korean Society for the Study of Obesity Guideline for the
*Corresponding author
Management of Obesity in Korea summarizes evidence-based recommendations and treatment guidelines.
Chong Hwa Kim

Key words: Obesity, Clinical practice guidelines, Korea

https://orcid.org/0000-0002-4563-7772

Division of Endocrinology and

Metabolism, Department of Internal
Medicine, Sejong General Hospital,
28 Hohyeon-ro 489beon-gil, Sosa-gu,
Bucheon 14754, Korea
Tel: +82-32-340-1116
Fax: +82-32-340-1236
E-mail: drangelkr@hanmail.net

INTRODUCTION Health Insurance Service, which stated that the prevalence of obe-
sity in Korea increased from 29.7% in 2010 to 35.7% in 2018. The
The Korean Society for the Study of Obesity (KSSO) published prevalence of abdominal obesity among Korean adults in 2018 was
a 2019 Obesity Fact Sheet based on data from the Korean National 23.8% (28.1% for men and 18.2% for women), indicating a steady

Copyright © 2021 Korean Society for the Study of Obesity

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits
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Kim BY, et al. Obesity Management: A Clinical Practice Guideline

increase from 19.0% in 2009.1 Obesity is associated with metabolic
abnormalities such as type 2 diabetes, dyslipidemia, insulin resis-
tance, metabolic syndrome, gallbladder disease, coronary artery
disease, hypertension, and cancer. There is an increased risk of co-
morbidities (directly linked with obesity) such as arthritis, back
pain, and sleep apnea. Therefore, obesity is associated with medical
and socio-economic burdens due to comorbidities. In addition, the
treatment and management of obesity is changing, reflecting new
clinical evidence.
The revised 2020 Obesity Treatment Guidelines (7th edition)
was based on the previous 2018 Obesity Treatment Guidelines
(6th edition), and included the latest research results. Levels of evi-
2
dence and a variety of clinical situations were taken into account
when formulating the recommended grades. In addition, changes
and developments in the 2019 anti-obesity drug market were re-
flected in the revised guidelines.
This treatment guideline was organized into questions divided
into nine major topics with the goal of increasing utilization in clin-
ical practice among primary care physicians treating obese patients.
The new revised guidelines summarize evidence-based recommen-
dations and treatment guidelines. The levels of evidence were clas-
sified into A, B, C, and D (Table 1). The standards of the recom-
mended grade were presented using a modified Grading of Recom-
mendation Assessments, Development and Evaluation (GRADE)
method3 and the grades were divided into classes I, IIa, IIb, and III.
Recommendations with low levels of evidence, but clear benefits
or high utilization rates in treatment according to user opinion sur-
vey results, were partially upgraded with the agreement of the treat-
ment guidelines committee. In order to determine the strengths of
recommendations, factors such as the level of evidence, the level of
use at primary care sites reflecting benefits and risks, practicability,
and acceptance were comprehensively considered (Table 1).
In this article, we introduce and briefly describe the 2020 Korean
Society for the Study of Obesity (KSSO) Guideline for the Man-
agement of Obesity in Korea.
RECOMMENDATIONS
This clinical practice guideline informs the arc of the patient
journey and the approach for clinical management of obesity in the
primary care setting. The guideline recommendations are shown in
Table 2 and include nine major themes: evaluation before obesity
treatment, behavioral therapy, physical activity, nutrition therapy,
pharmacotherapy, bariatric surgery, obesity in the elderly, obesity in
children and adolescents, and metabolic syndrome. The purpose
of the guideline is as follows. First, it helps practitioners, who are

Table 1. Levels of evidence and recommended grades

Definition
Level of evidence
A There is good research-based evidence to support the recommendation.
Data derived from at least 1 randomized controlled trial, meta-analysis or systematic review
B There is fair research-based evidence to support the recommendation.
Data derived from at least 1 well designed cohort or case-control study without randomization
C There is fair evidence but it is insufficient to support the recommendation.
Data derived from case series or observational studies
D The recommendation is based on expert opinion and panel consensus.
Consensus of expert opinions based on experience
Recommended grade
Class I The recommendation is supported by level of evidence A. Is recommended
Clinically important outcomes and the study population is representative of the population in the recommendation.
Class IIa The recommendation is supported by level of evidence B. Should be considered
Clinically important or validated surrogate outcomes.
Class IIb The recommendation is supported by level of evidence C or D. May be considered
The outcome is an unvalidated surrogate condition but clinically important outcomes.
Class III The recommendation is supported by level of evidence C or D. Is not recommended
Outcome is an unvalidated surrogate for clinically important population, or the applicability of the study is irrelevant.
Data from Schünemann et al.3

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Kim BY, et al. Obesity Management: A Clinical Practice Guideline

Table 2. Recommendations for the management of obesity

Category of evidence and
Recommendation
strength of recommendation
Evaluation before obesity treatment
1. The definition for obesity in adults is BMI ≥ 25 kg/m2. Abdominal obesity is detected by measuring the waist circumference and is defined B, Class IIa
as ≥ 90 cm and ≥ 85 cm for adult men and women, respectively.
2. Obesity is classified into primary obesity, commonly known as simple obesity, and secondary obesity, which can be caused by genetics, B
endocrine diseases, and drugs.
3. Obesity increases the risk of type 2 diabetes, hypertension, dyslipidemia, coronary artery disease and metabolic syndrome, and increases A
total mortality, cancer mortality, and cardiovascular mortality.
4. It is recommended that treatment is determined through sufficient discussion between the patient and physician about the benefits and C, Class I
risks associated with weight loss. While recommending treatments for obesity to patients, doctors must ensure that patients are ready
to participate in weight loss.
5. It is recommended to lose 5%–10% of body weight within 6 months after starting treatment as the primary goal of weight loss. A, Class I
Nutrition therapy in obesity management
6. In order to lose weight, it is recommended that energy intake should be reduced, and the degree of energy restriction should be A, Class I
individualized according to individual characteristics and medical conditions.
7. Various dietary methods (low calorie diet, low carb diet, low fat diet, high protein diet) can be selected, but energy intake can be reduced, A, Class I
and nutritionally appropriate methods are recommended.
8. It is recommended to individualize the composition of macronutrients (carbohydrates, fats, proteins) according to individual characteristics C, Class I
and medical conditions.
9. Very-low calorie diet should be implemented only in limited circumstances, and intensive interventions are recommended to be carried out A, Class I
to improve lifestyles along with medical monitoring.
Physical activity in obesity management
10. It is recommended to assess participation in physical activity and conduct health status evaluation before physical activity. In patients with A, Class I
symptoms of cardiovascular, metabolic, or kidney disease, it is recommended to start physical activity after consulting the patient’s doctor.
Otherwise, low to moderate intensity of physical activity is recommended initially.
11. For weight loss, it is recommended to perform aerobic exercise for at least 150 minutes per week or 3–5 times a week. A, Class I
Additional resistance training 2–4 times a week using large muscle groups should be considered to lose weight. A, Class IIa
12. Physical activity alone does not have a great effect on weight loss, so we recommend physical activity combined with nutrition therapy. A, Class I
13. For weight loss, a combination of aerobic exercise and resistance exercise should be considered because it is more effective than aerobic A, Class IIa
exercise alone and resistance exercise alone. There is no significant difference between high-intensity exercise and moderate-intensity
exercise in terms of weight loss effect.
Behavior therapy in obesity management
14. For weight loss, it is recommended to improve lifestyle through interventions such as reducing food intake and increasing physical activity. A, Class I
15. For effective weight loss, it is recommended that a trained therapist performs behavior therapy for more than 6 months. A, Class I
16. For effective weight maintenance, it is recommended that a trained therapist performs behavioral therapy for at least 1 year. A, Class I
17. It is recommended that obese people be suspected to have eating disorders if they are observed with excessive weight or body type in A, Class I
self-assessment, various weight control behaviors to offset the effects of binge eating, or binge eating.
18. In the case of behavioral therapy for weight loss, smoking cessation counseling should be performed. B, Class IIa
19. In the case of behavioral therapy for weight loss, we recommend alcohol counseling. A, Class I
20. For the treatment of sleep apnea, it is recommended to lose weight through behavioral therapy. A, Class I
Pharmacotherapy in obesity management
21. The basic treatments for obesity include nutrition therapy, physical activity, and behavior therapy, and we recommend pharmacotherapy as A, Class I
an additional treatment alongside comprehensive lifestyle intervention.
22. In cases of failure to lose weight through lifestyle intervention in patients with BMI ≥ 25 kg/m2, pharmacotherapy should be considered. B, Class IIa
23. For long-term weight management, it is recommended that drugs approved based on the large-scaled clinical trials should be used. B, Class I
24. It is recommended that the pharmacotherapy be changed or discontinued if weight loss is not greater than 5% within 3 months of A, Class I
pharmacotherapy.
Bariatric surgery
25. Bariatric surgery should be considered to maintain weight loss and for weight loss in patients with severe obesity and to improve A, Class IIa
accompanying diseases related to obesity, including type 2 diabetes.
26. Bariatric surgery should be considered in patients with failure to lose weight despite optimal medical and behavioral management in whom B, Class IIa
with BMI ≥ 35 kg/m2 or BMI ≥ 30 kg/m2 and obesity-related comorbidities.
(Continued to the next page)

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Kim BY, et al. Obesity Management: A Clinical Practice Guideline

Table 2. Continued
Category of evidence and
Recommendation
strength of recommendation
27. Bariatric surgery should be considered in patients with type 2 diabetes with BMI ≥ 27.5 kg/m2 or poorly controlled blood glucose despite B, Class IIa
optimal medical management.
28. Sleeve gastrectomy, Roux-en-Y gastric bypass surgery, adjustable gastric band surgery, and biliopancreatic diversion surgery are standard A, Class I
procedures with established effectiveness and safety.
29. Before surgery, it is recommended to obtain past medical and psychosocial history and perform physical examination and diagnostic test to A, Class I
evaluate the safety of the surgery.
30. Preoperative micronutrient examination is required, and follow-up examination is recommended according to the schedule after the surgery A, Class I
31. Multidisciplinary treatment should be considered before and after surgery to increase the treatment effectiveness and safety. C, Class IIa
Obesity in children and adolescents
32. It is recommended to prevent and treat childhood and adolescent obesity because they often develop into adult obesity and can cause A, Class I
accompanying diseases.
33. Treatment for childhood and adolescent obesity is recommended to provide the energy and nutrients needed for normal growth and main- A, Class I
tain appropriate weight with proper lifestyle modifications.
34. When diagnosing obesity in children and adolescents over the age of 2, BMI percentiles by sex and age are based on the 2017 Child and A, Class I
Adolescent Growth Chart. BMI ≥ the 85th percentile is defined as pre-obesity, and ≥ the 95th percentile is defined as obesity.
35. Individualized risk assessment should be considered in children and adolescents with pre-obesity or obesity. B, Class IIa
36. For the treatment of obesity in children and adolescents, comprehensive lifestyle interventions including nutrition therapy, physical activity, A, Class I
and behavior therapy are recommended.
37. When comprehensive lifestyle interventions including nutrition therapy, physical activity, and behavior therapy fail to result in appropriate B, Class IIa
weight loss and comorbidities are not controlled, pharmacotherapy by an experienced specialist should be considered.
Obesity in the elderly
38. For diagnosis of obesity in the elderly, it is recommended to evaluate waist circumference along with BMI. A, Class I
39. Weight loss in the elderly should be considered when the benefits of weight loss are greater than the status. B, Class IIa
40. In the treatment of obesity in the elderly, a protein-rich low-calorie diet and increased physical activity are recommended. A, Class I
41. In the treatment of obesity in the elderly, pharmacotherapy and surgical treatment may be considered with regard to individual B, Class IIb
comorbidities, other medications, and safety
Metabolic syndrome
42. As the severity of obesity increases, the incidence of metabolic syndrome increases. A
43. The clinical significance of metabolic syndrome can predict the occurrence of diabetes and cardiovascular disease, and increases morbidity A
and mortality caused by cardiovascular disease
44. Diagnosis of metabolic syndrome in adults in Korea requires ≥ 3 of the five following criteria: waist circumference ≥ 90 cm (men) or D
≥ 85 cm (women), blood pressure ≥ 130/85 mmHg or taking anti-hypertensive medication, fasting blood glucose ≥ 100 mg/dL or taking
anti-diabetic medication, triglycerides ≥ 150 mg/dL, HDL cholesterol < 40 mg/dL (men), or 50 mg/dL (women), or taking anti-dyslipidemia
medication.
45. For the treatment of metabolic syndrome, lifestyle intervention and treatment of each component should be considered. A, Class IIa
BMI, body mass index; HDL, high-density lipoprotein.

the main users of the guideline, to make safer and more effective
decisions by providing evidence-based recommendations with
clear evidence levels and benefits. Second, it provides high-quality
evidence-based information for primary care physicians.
EVALUATION BEFORE OBESITY
TREATMENT
Diagnosis of obesity is important in the evaluation stage before
obesity treatment. Body mass index (BMI), which is a value ob-
tained by dividing body weight (kg) by the square of height (m ),
is highly correlated with body fat mass, and because BMI can be
used to evaluate health risks such as morbidity and mortality of
obesity-associated diseases, BMI is the most commonly used index
to diagnose obesity. The World Health Organization (WHO) de-
fines obesity as BMI ≥ 30 kg/m2. However, East Asians, including
Koreans, have increased risk of diabetes and cardiovascular disease
even below BMI of 25 kg/m2 and higher abdominal fat and body
fat percentages than Westerners at the same BMI.4 There is con-
cern that the general WHO definition of obesity underestimates
health risks associated with obesity in East Asians. The classifica-
2
tion of obesity into classes I, II, and III relies on adult BMI in accor-

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Kim BY, et al. Obesity Management: A Clinical Practice Guideline

Table 3. Definitions of obesity and risk of comorbidity according to obesity and ergy intake by 500–1,000 kcal, in which case a weight loss effect of
abdominal obesity in Koreans
0.5–1.0 kg per week is expected.9 Therefore, based on the results of
Risk of comorbidity according to abdominal obesity
several studies, a low-calorie diet that reduces energy intake by
Classification < 90 cm (men), ≥ 90 cm (men),
< 85 cm (women) ≥ 85 cm (women) 500–1,000 kcal per day can bring about weight loss without nega-
BMI (kg/m2) tive health effects and is also relatively easy to follow. Limiting total
Underweight (< 18.5) Low Average energy intake is important for the treatment of obesity, but there is
Normal (18.5–22.9) Average Increased
a continuing interest in the effects of dietary macronutrients, espe-
Pre-obesity (23.0–24.9) Increased High
Class I obesity (25.0–29.9) High Severe cially carbohydrate composition, on weight loss. In the early 2000s,
Class II obesity (30.0–34.9) Severe Very severe some randomized controlled studies reported that low-carb diets
Class III obesity (≥ 35.0) Very severe Very severe resulted in greater initial weight loss than traditionally recommend-
Pre-obesity may be defined as overweight or at-risk weight, and class III obesity may ed low-fat diets.10 The definition of a low-carbohydrate diet is not
be defined as extreme obesity.
BMI, body mass index. clear and varies according to researchers, but diets with daily carbo-
hydrate intake of more than 130 g and less than 45% of total energy
dance with WHO guidelines for the Asia-Pacific region. Class I 5
are classified as low-carbohydrate diets, while diets with a daily car-
obesity is defined as BMI 25.0 to 29.9 kg/m , class II obesity is de-
2
bohydrate intake of less than 130 g are sometimes classified as very-
fined as BMI 30.0 to 34.9 kg/m , and class III obesity was newly
2
low carbohydrate diets.11 Several studies indicated that low carbo-
defined in 2018 as ≥ 35.0 kg/m2 (Table 3). hydrate diets resulted in significantly greater weight loss during the
Waist circumference (WC) is highly associated with intra-ab- initial 6 months compared to control diets.10,12,13 This difference
dominal fat.6 WC is measured in the horizontal plane midway be- from the control group persisted at 1 year, but compared to the ini-
tween the superior iliac crest and the lower margin of the last rib. 7
tial 6 months, the difference was reduced.14-16
According to the KSSO, abdominal obesity in Koreans is defined Increasing total fat intake through a very-low carbohydrate diet is
as WC ≥ 90 cm in men and ≥ 85 cm in women (Table 3). In the likely to be accompanied by increased intake of saturated fatty acids
case of abdominal obesity, the morbidity and mortality of metabol- and trans-fatty acids, and several studies report that such intake has
ic syndrome, diabetes, and coronary artery disease increase inde- negative effects on vasodilating capacity at the initiation of very-low
pendently of BMI, so it is necessary to increase the risk of comor- carb diets.17-19 Adhering to a low-carb diet can be considered a
bidities classified by BMI to the next level (Table 3). method of weight loss, but is not effective in the long term and may
In some obese patients, secondary obesity is caused by genetic negatively affect cardiovascular health, so it is necessary to pay spe-
and congenital disorders, drugs, neurological and endocrine disor- cial attention to fatty acid composition.
ders, and psychiatric disorders. In patients with secondary obesity,
8
Consistently limiting energy intake can help in losing weight, but
relatively effective weight loss can be expected after accurate identi- many individuals find it difficult to follow a strict energy-restricted
fication of the cause, so discerning secondary obesity is very impor- diet.19 Interest in intermittent fasting as an alternative to sustained
tant. Obesity causes metabolic abnormalities as well, and even if energy-restricted diets has increased. Intermittent fasting has many
metabolic abnormalities are not present, obesity itself causes com- forms. Meta-analyses of intermittent fasting and time-limited diets
plications. Therefore, it is necessary to evaluate the comorbidities suggest that these dietary methods can result in levels of weight loss
of obesity when treating obese patients. effect equivalent to those accomplished via continuous energy-re-
stricted diet, but related studies, especially regarding long-term ef-
MEDICAL NUTRITION THERAPY fects, are insufficient. There is limited evidence to include intermit-
tent fasting as a method of dietary treatment, and further studies
To lose weight, it is necessary to reduce energy intake. Many are needed. The KSSO guidelines summarize the characteristics of
weight control programs prescribe low-calorie diets that reduce en- each dietary treatment.20

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Kim BY, et al. Obesity Management: A Clinical Practice Guideline
PHYSICAL ACTIVITY
Exercise and physical activity are important factors in lifestyle in-
terventions for weight loss. The weight loss effect of exercise rarely
exceeds 5%, but exercise and physical activity reduce the risks asso-
ciated with various metabolic factors such as weight, body fat per-
centage, and visceral fat, and improves lean mass and functional
ability.21,22 In addition, exercise with nutrition therapy has been
found to be more effective than nutrition therapy alone, or exercise
without nutrition therapy.23
In individuals with no cardiovascular, metabolic, or kidney dis-
ease, and no signs or symptoms, there is no need for medical per-
mission before prescribing exercise for either regular exercise par-
ticipants or non-participants. In accordance with the exercise
24
guidelines, non-participants in regular exercise can start with low
and moderate intensity exercise, while regular exercise participants
may begin with moderate and high intensity exercise and gradually
increase exercise intensity. Regular exercise participants with un-
derlying cardiovascular (heart, peripheral artery, or cerebrovascu-
lar) disease, metabolic disease (type 1 or type 2 diabetes), or kid-
ney disease, but who are asymptomatic, do not need medical per-
mission to engage in moderate intensity exercise. Medical permis-
sion is recommended prior to high-intensity exercise. 24
Aerobic exercise is an essential tool in weight loss programs ad-
dressing obesity. It is recommended to perform moderate-intensity
exercise at least 150 minutes per week, 3–5 times a week, starting
with low-intensity exercise and gradually increasing the intensity
and amount of exercise according to individual fitness level. Resis-
tance training should be prescribed in a weight loss exercise pro-
gram to increase lean mass and promote body fat loss, and it is rec-
ommended to perform exercise using large muscle groups 2–4
times a week. 25
BEHAVIOR THERAPY
Behavior therapy can be applied not only as a programmed be-
havior intervention for weight control, but also for the purpose of
changing behaviors related to food intake and physical activity.
Treating obesity has long been known to be more effective when
lifestyle interventions including behavioral therapy are performed.
86 | https://www.jomes.org
Therefore, all obese people should undergo behavioral therapy,
along with nutrition therapy and increased physical activity. Specif-
ic methods used in behavioral therapy include self-monitoring, re-
inforcement, stimulus control, alternative behavior, and cognitive
reconstruction.
When treating obesity, it is very important to diagnose and treat
any eating disorders that may exist. Eating disorders should be con-
sidered when binge eating, weight control behaviors to offset the
effects of binge eating, and excessive emphasis on weight or body
shape are observed in obese people. Obese people with eating dis-
orders benefit from psychological therapies such as guided self-
help or cognitive behavior therapy focused on eating disorders.26
When treating obesity, smoking and alcohol consumption must
be reduced. Obese people should be advised to quit smoking.27 Al-
cohol has a high caloric content of about 7.1 kcal per gram, and the
liver produces fat in trace amounts.28,29 In addition, most ingested
alcohol is converted to acetate, which interferes with peripheral fat
breakdown and utilization. Clinically, alcohol raises blood pressure,
and excessive drinking increases the risk of hypertriglyceridemia,
insulin resistance, type 2 diabetes, metabolic syndrome, and ab-
dominal obesity. Therefore, controlling excessive drinking is im-
portant for the prevention and control of obesity and metabolic
syndrome.30
PHARMACOTHERAPY
The basic treatments for obesity are nutrition therapy, physical
activity, and behavior therapy. We recommend pharmacotherapy
as an additional treatment alongside comprehensive lifestyle inter-
vention. According to the KSSO guideline, pharmacotherapy should
be considered when non-pharmacotherapy-treated patients with
BMI ≥ 25 kg/m2 fail to lose weight (Fig. 1). Not all obese people
respond to obesity drugs, and there are a significant number of non-
responders. A commonly used criterion for predicting treatment
response is weight loss of 5% or more within the initial 3 months. If
there is no weight loss of more than 5% within 3 months of initiat-
ing the drug, pharmacotherapy should be changed or discontinued.
As of 2020, four types of obesity treatments have been approved
for long-term administration in Korea: orlistat (Xenical), naltrex-
one-bupropion (Contrave), liraglutide (Saxenda), and phenter-
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Kim BY, et al. Obesity Management: A Clinical Practice Guideline

BMI 23.0–24.9 (overweight)

Measure weight, Yes Assess and treat CVD risk
Patient BMI 25.0–29.9 (class I obesity)
height; calculate factors and obesity-related
encounter BMI 30.0–34.9 (class II obesity) BMI ≥ 25.0
BMI (kg/m2) diseases
BMI ≥ 35.0 (class III obesity)

Comprehensive
lifestyle modification

Follow-up and maintenance of comprehensive Yes Weight loss ≥ 5% and sufficient

lifestyle modification improvement in health targets

No

Follow-up and maintenance of Yes Weight loss ≥ 5% and sufficient Intensive lifestyle intervention
comprehensive lifestyle
improvement in health targets and pharmacotherapy
modification

No

BMI ≥ 35.0 or ≥ 30.0 with obesity-related

diseases: consider bariatric/metabolic surgery

Figure 1. Treatment algorithm for the primary care of patients with obesity. BMI, body mass index; CVD, cardiovascular disease.

mine-topiramate (Qsymia).31 These drugs have been approved for
use in the treatment of obesity based on the results of clinical stud-
ies on long-term use. Lorcaserin (Belviq) was used as a treatment
for obesity from February 2015 to February 2020, but due to in-
creased risk of cancer, it was voluntarily withdrawn from the mar-
ket in the Unites States and discontinued from sales in Korea.
These four drugs induce significant weight loss when administered
together with lifestyle modifications, and result in improvement
and prevention of various complications. Anti-obesity drugs must
be prescribed according to the characteristics of each patient, and
the presence of other comorbidities is important when choosing
drugs. Table 4 guides the selection of anti-obesity drugs according
to comorbidities.
BARIATRIC SURGERY
According to the International Federation for the Surgery of
Obesity and Metabolic Disorders, Asian Pacific Chapter Consen-
sus statements 2011(IFSO-APC consensus statements), the indi- 33
cations of bariatric surgery are failure to lose weight due to nonsurgi-
cal treatment in patients with BMI ≥ 35 kg/m2 or BMI ≥ 30 kg/m2
and obesity-related comorbidities, and this indication is applied in
Korea. In Korea, from January 2019, the national health insurance
plan has covered bariatric surgery performed for the purpose of
treatment in patients with severe obesity. In patients with BMI
32
≥ 35 kg/m2 or BMI ≥ 30 kg/m2 and obesity-related comorbidities,
health insurance benefits are applied.
Types of bariatric surgery can be largely divided into restrictive
surgery, malabsorptive surgery, and combined surgery. Restrictive
surgeries include sleeve gastrectomy and adjustable gastric band-
ing, and malabsorptive surgery is defined as biliopancreatic diver-
sion/duodenal switch (Table 5). The typical combined surgery is
Roux-en-Y gastric bypass, which results in both restriction and ab-
sorption inhibition (Table 5). These surgeries are standard proce-
dures that have already proven their effectiveness and safety,34 and
since each surgical method has advantages and disadvantages, it is
important to select an appropriate surgical method according to
each patient’s situation. In addition, in order to secure the safety
and efficiency of patient management before and after surgery, col-
laboration across various departments is essential.

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Kim BY, et al. Obesity Management: A Clinical Practice Guideline

Table 4. Individualization of anti-obesity medications

Anti-obesity medication
Coexisting disease
Orlistat Naltrexone ER/bupropion ER Liraglutide 3 mg Phentermine/topiramate ER
Type 2 diabetes
Hypertension Monitor blood pressure and Monitor heart rate Monitor heart rate
heart rate
Contraindicated in uncontrolled
hypertension
Coronary arterial Monitor blood pressure and
disease heart rate
Chronic kidney Mild (50–79 mL/min)
disease
Moderate (30–49 mL/min) Do not exceed 8 mg/90 mg/day Do not exceed 7.5 mg/46 mg/day
Severe (< 30 mL/min) Watch for oxalate stone
Hepatic Mild–moderate (Child-Pugh 5–9) Watch for cholelithiasis Do not exceed 8 mg/90 mg/day Watch for cholelithiasis Do not exceed 7.5 mg/46 mg/day
impairment Severe (Child-Pugh > 9)
Glaucoma Contraindicated, may trigger Contraindicated, may trigger
angle closure angle closure
Pancreatitis Avoid if prior or current
disease
, preferred use; , use with caution; , avoid.
ER, extended release.

OBESITY IN CHILDREN AND
ADOLESCENTS
Obesity in children and adolescents is rapidly increasing due to
changes in diet, living environment, and decreases in physical activ-
ity. Obesity in children and adolescents is a chronic disease that is
difficult to treat. It easily develops into adult obesity and requires a
healthy diet and active lifestyle throughout life. Therefore, a policy
of early detection and treatment should be established.
For the evaluation of obesity in children and adolescents, it is im-
portant to continuously evaluate obesity trends according to growth
and development status through regular check-ups.35 The most
widely used indicator is BMI. Percentile of BMI by sex and age is
used to evaluate obesity in children and adolescents aged 2 years or
older. In addition, since the growth and development period and
body composition may differ depending on ancestry, standard val-
ues for Korean children and adolescents are applied. Age is calcu-
lated in months. Children or adolescents with BMI above the
35
85th percentile are considered overweight, those above the 95th
percentile are obese, and those below the 85–95th percentile are
regarded as pre-obesity. 35
Considering the effects of obesity and obesity treatment on
growth and development, it is important to prepare a treatment
strategy for maintaining appropriate weight and avoiding uncondi-
tional weight loss.36-41 The key to the treatment of obesity in chil-
dren and adolescents is to maintain an appropriate weight by in-
ducing and continuing lifestyle modifications. Orlistat is the only
drug approved by the U.S. Food and Drug Administration for us-
age by those over 12 years of age.42,43
OBESITY IN THE ELDERLY
Body weight is gained naturally with age and in the elderly, mor-
tality does not increase with BMI ≥ 25 kg/m2. The mortality rate
in the elderly population is influenced not only by weight but also
by other variables such as comorbidities.44 Therefore, for the diag-
nosis of obesity in the elderly, it is recommended to measure WC
together with BMI, and indicators such as the WC to height ratio
and the WC to hip circumference ratio can also be utilized.45
Weight loss is recommended for elderly patients when it is
judged that the benefits gained through weight loss during obesity
treatment are greater than the harms. Even in the elderly, weight
loss through lifestyle modifications such as diet control and physi-
cal activity is first considered and positive effects can be expected
such as improving physical function and cardiovascular index.46
Well-designed studies of the effectiveness and safety of anti-obe-

88 | https://www.jomes.org J Obes Metab Syndr 2021;30:81-92

Kim BY, et al. Obesity Management: A Clinical Practice Guideline

Table 5. Types of bariatric surgery

Type of surgery
Biliopancreatic diversion/
Adjustable gastric banding Sleeve gastrectomy Roux-en-Y gastric bypass
duodenal switch
Schematic diagram

History (yr) 30 10–15 50 (Most historical) 20

Surgical technique
Mechanism of weight loss
Reversibility
Effect of weight loss
(mid- to long-term %EWL*)
Advantages and
disadvantages,
Complications
*Percentage of EWL: the rate of loss of excess weight based on body mass index of 25 kg/m²; †Long-term follow-up data for more than 10 years is not yet sufficient.
EWL, excess weight loss.
Placement of an adjustable band Longitudinal resection of the Creation of small gastric pouch Sleeve gastrectomy with
to retain a small amount of stomach to achieve about 80% (about 30 mL) with diversion of duodenal-ileal anastomosis
gastric reservoir (15–20 mL) gastric volume reduction digestive pathway (bypassing (bypassing the entire jejunum
the residual stomach and upper and proximal part of ileum)
gastro-intestinal tract)
Intake restriction Intake restriction Intake restriction (+absorption Intake restriction+absorption
restriction) restriction
Reversible Irreversible Partially reversible Partially reversible
2 yr: 50% 2 yr: 60% 2 yr: 70% 2 yr: 70%–80%
10 yr: 40% 10 yr: 50%–55%† 10 yr: 60% 10 yr: 70%
The frequency of implementation Occurrence or deterioration of Difficulties in endoscopic screening Depletion of protein and trace
is decreasing because of gastro-esophageal reflux after of the bypassed stomach elements occurs frequently
relatively high incidence of surgery Risk of dumping syndrome and Life-long supplementation of
visceral complications related to Relatively high incidence of weight marginal ulcer deficient nutrients is needed
foreign material (30%–40% of regain at long-term follow-up Regular checkup and appropriate
band removal or revisional supplementation is required for
surgery is required within prevention of trace element
10 years). deficiency

sity medications in the elderly are insufficient. Among drugs for obe-
sity treatment approved for long-term use, orlistat can be safely used
for elderly patients. Bariatric surgery in the elderly seems to be
47
helpful for treating weight loss or diabetes, 48,49
but caution is neces-
sary because the risk of complications after surgery may increase.
METABOLIC SYNDROME
Metabolic syndrome is the term for a combination of metabolic
abnormalities such as hyperglycemia, high blood pressure (hyper-
tension) and obesity. Diagnosis criteria for metabolic syndrome
51
are in the process of being integrated, as different organizations
have different criteria. International Diabetes Federation criteria for
diagnosing metabolic syndrome begin with the recognition of ab-
dominal obesity as the most important etiology, and therefore, ab-
dominal obesity is an essential requirement for diagnosing meta-
bolic syndrome. In addition, one of the main features is that it is
recommended to use WC measurements suitable for different groups
in recognition that the diagnostic criteria for abdominal obesity may
50
differ by ancestry. In 2007, based on the results of the National Health
and Nutrition Survey, Korea recognized abdominal obesity when
the WC was more than 90 cm for men and 85 cm for women,52 and
a recent study found that this criterion was appropriate for Koreans.
Diagnosis of metabolic syndrome in Korean adults requires ≥ 3 of
the following five criteria: WC of ≥ 90 cm (men) or ≥ 85 cm (wom-
en), blood pressure ≥ 130/85 mmHg or taking anti-hypertensive
medication, fasting blood glucose ≥ 100 mg/dL or taking anti-dia-
betic medication, triglycerides ≥ 150 mg/dL, and high-density li-
poprotein cholesterol < 40 mg/dL (men) or 50 mg/dL (women)
or taking anti-dyslipidemia medication.

J Obes Metab Syndr 2021;30:81-92 https://www.jomes.org | 89

Kim BY, et al. Obesity Management: A Clinical Practice Guideline
The goal of metabolic syndrome treatment is to prevent cardio-
cerebrovascular diseases and diabetes. There are two major thera-
peutic approaches to metabolic syndrome. One is lifestyle modifi-
cation to reduce insulin resistance, which is the cause of metabolic
syndrome, and the other is pharmacotherapy for each component
of metabolic syndrome.
CONCLUSION
Obesity is a disease associated with increased socioeconomic
burden due to increased risk of obesity-related comorbidities. Since
obesity is multifactorial, treatments for obesity include comprehen-
sive lifestyle interventions such as nutrition therapy, physical activi-
ty, behavior therapy, and pharmacotherapy. The proper surgical
management of obesity requires a multidisciplinary treatment
team. This new guideline helps primary care physicians make safer
and more effective decisions by providing evidence-based recom-
mendations with clear evidence levels and high-quality evidence-
based information. More efforts are needed to improve the quality
of obesity treatment and management in Korea.
CONFLICTS OF INTEREST
Ga Eun Nam has worked as an Associate Editor of the journal
since 2020. However, she was not involved in the peer reviewer se-
lection, evaluation, or decision process of this article. Otherwise,
no other potential conflicts of interest relevant to this article were
reported.
ACKNOWLEDGMENTS
This work was supported by the Korean Society for the Study of
Obesity.
AUTHOR CONTRIBUTIONS
Study concept and design: BYK and CHK; acquisition of data:
SMK, JHK (Jee-Hyun Kang), SYK, KKK, and BK; analysis and
interpretation of data: SJK, YHK, JHK (Jae Hyun Kim), HL, EJJ,
SC, KBK, YAS and YHH; drafting of the manuscript: BYK and
90 | https://www.jomes.org
CHK; critical revision of the manuscript: BYK, EMK, SMK, JHK
(Jee-Hyun Kang), SYK, KKK, BK, SJK, YHK, JHK (Jung-Hwan
Kim), JHK (Jae Hyun Kim), GEN, JYP, JWS, HJS, TJO, HL, EJJ,
SC, YHH, YAS and CHK; statistical analysis: SJK, YHK, and JHK
(Jung-Hwan Kim); obtained funding: BYK and CHK; administra-
tive, technical, or material support: BYK and CHK; and study su-
pervision: CHK.
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